Healthcare Provider Details

I. General information

NPI: 1457388035
Provider Name (Legal Business Name): ALEXIS M WAGUESPACK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 HOUMA BLVD STE 18
METAIRIE LA
70006-2921
US

IV. Provider business mailing address

3939 HOUMA BLVD STE 18
METAIRIE LA
70006-2921
US

V. Phone/Fax

Practice location:
  • Phone: 504-392-7123
  • Fax: 504-392-7823
Mailing address:
  • Phone: 504-392-7123
  • Fax: 504-392-7823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberMD.09377R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: